Summary of Benefits

Summary of Benefits 2021 Ascension Complete St. Vincent's Secure (HMO) H4343: 003 Bibb, Blount, Jefferson, Shelby and St. Clair counties, AL H4343_003_21_19220SB_M Accepted 09012020 This booklet provides you with a summary of what we cover and the cost-sharing responsibilities. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please call us at the number listed on the last page, and ask for the “Evidence of Coverage” (EOC), or you may access the EOC on our website at http://www.ascensioncomplete.com. You are eligible to enroll in Ascension Complete St. Vincent’s Secure (HMO) if: • You are entitled to Medicare Part A and enrolled in Medicare Part B. Members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. • You must be a United States citizen, or are lawfully present in the United States and permanently reside in the service area of the plan (in other words, your permanent residence is within the Ascension Complete St. Vincent’s Secure (HMO) service area counties). Our service area includes the following counties in Alabama: Bibb, Blount, Jefferson, Shelby, and St. Clair. The Ascension Complete St. Vincent’s Secure (HMO) plan gives you access to our network of highly skilled medical providers in your area. You can look forward to choosing a Primary Care Physician (PCP) to work with you and coordinate your care. You can ask for a current provider and pharmacy directory or, for an up-to-date list of network providers, visit http://www.ascensioncomplete.com. (Please note that, except for emergency care, urgently needed care when you are out of the network, out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers, if you obtain medical care from out-of-plan providers, neither Medicare nor Ascension Complete St. Vincent’s Secure (HMO) will be responsible for the costs.) This Ascension Complete St. Vincent’s Secure (HMO) plan also includes Part D coverage, which provides you with the ease of having both your medical and prescription drug needs coordinated through a single convenient source. Summary of Benefits January 1, 2021 – December 31, 2021 Benefits Ascension Complete St. Vincent's Secure (HMO) H4343: 003 Premiums / Copays / Coinsurance Monthly Plan Premium $0 You must continue to pay your Medicare Part B premium. Deductibles No deductible Maximum Out-of-Pocket $5,000 annually Responsibility This is the most you will pay in copays and coinsurance for (does not include covered medical services for the year. prescription drugs) Inpatient Hospital For each admission, you pay: Coverage* • $290 copay per day, for days 1 through 6 • $0 copay per day, for days 7 and beyond Outpatient Hospital • Outpatient Hospital: $250 copay per visit Coverage* • Observation Services: $250 copay per visit Doctor Visits (Primary • Primary Care: $0 copay per visit Care Providers and • Specialist: $25 copay per visit Specialists) Preventive Care $0 copay for most Medicare-covered preventive services (e.g. flu vaccine, Other preventive services are available. diabetic screening) Emergency Care $90 copay per visit You do not have to pay the copay if admitted to the hospital immediately. Services with an * (asterisk) may require prior authorization from your doctor. Benefits Ascension Complete St. Vincent's Secure (HMO) H4343: 003 Premiums / Copays / Coinsurance Urgently Needed $25 copay per visit Services Copay is not waived if admitted to hospital. Diagnostic Services/ COVID-19 testing and specified testing-related services at Labs/Imaging* any location are $0. (includes diagnostic • Lab services: $0 copay tests and procedures, • Diagnostic tests and procedures: $0 copay labs, diagnostic • radiology, and X-rays) Outpatient X-ray services: $0 copay • Diagnostic Radiology Services (such as, MRI, MRA, CT, PET): 20% coinsurance (up to $100) Hearing Services • Hearing exam (Medicare-covered): $25 copay • Routine hearing exam: $0 copay (1 every calendar year) • Hearing aid: $0 to $1,350 copay (2 hearing aids total, 1 per ear, per calendar year) Dental Services • Dental services (Medicare-covered): $25 copay per visit • Preventive Dental Services: $0 copay (including oral exams, cleanings, fluoride treatment, and X-rays) • Comprehensive dental services: Additional comprehensive dental benefits are available. There is a benefit maximum allowance of $3,000 every calendar year; it applies to all comprehensive dental benefits. Vision Services • Vision exam (Medicare-covered): $0 to $25 copay per visit • Routine eye exam: $0 copay per visit (up to 1 every calendar year) • Routine eyewear: up to $150 allowance every calendar year Services with an * (asterisk) may require prior authorization from your doctor. Benefits Ascension Complete St. Vincent's Secure (HMO) H4343: 003 Premiums / Copays / Coinsurance Mental Health Services Individual and group therapy: $25 copay per visit Skilled Nursing Facility* For each benefit period, you pay: • $0 copay per day, days 1 through 20 • $184 copay per day, days 21 through 100 Physical Therapy* $25 copay per visit Ambulance $250 copay (per one-way trip) for ground or air ambulance services Ambulatory Surgery Ambulatory Surgery Center: $190 copay per visit Center * Transportation • $0 copay (per one-way trip) • Up to 20 one-way trips to plan-approved health-related locations every calendar year. Mileage limits may apply. Medicare Part B Drugs* • Chemotherapy drugs: 20% coinsurance • Other Part B drugs: 20% coinsurance Services with an * (asterisk) may require prior authorization from your doctor. Part D Prescription Drugs Deductible Stage This plan does not have a Part D deductible. Initial Coverage Stage After you have met your deductible (if applicable), the plan (after you pay your pays its share of the cost of your drugs and you pay your Part D deductible, if share of the cost. You generally stay in this stage until the applicable) amount of your year-to-date “total drug costs” reaches $4,130. “Total drug costs” is the total of all payments made for your covered Part D drugs. It includes what the plan pays and what you pay. Once your “total drug costs” reach $4,130 you move to the next payment stage (Coverage Gap Stage). Standard Retail Mail Order Rx 30-day supply Rx 90-day supply Tier 1: Preferred Generic $0 copay $0 copay Drugs Tier 2: Generic Drugs $10 copay $20 copay Tier 3: Preferred Brand $47 copay $141 copay Drugs Tier 4: Non-Preferred $100 copay $300 copay Drugs Tier 5: Specialty 33% coinsurance Not available Tier 6: Select Care Drugs $0 copay $0 copay Part D Prescription Drugs Coverage Gap Stage During this payment stage, you receive a 70% manufacturer’s discount on covered brand-name drugs and the plan will cover another 5%, so you will pay 25% of the negotiated price and a portion of the dispensing fee on brand-name drugs. In addition, the plan will pay 75% and you pay 25% for generic drugs. (The amount paid by the plan does not count towards your out-of-pocket costs). You generally stay in this stage until the amount of your year-to-date “out-of-pocket costs” reaches $6,550. “Out of pocket costs” includes what you pay when you fill or refill a prescription for a covered Part D drug and payments made for your drugs by any of the following programs or organizations: “Extra Help” from Medicare; Medicare’s Coverage Gap Discount Program; Indian Health Service; AIDS drug assistance programs; most charities; and most State Pharmaceutical Assistance Programs (SPAPs). Once your “out-of-pocket costs” reach $6,550, you move to the next payment stage (Catastrophic Coverage Stage). Catastrophic Coverage During this payment stage, the plan pays most of the cost Stage for your covered drugs. For each prescription, you pay whichever of these is greater: a payment equal to 5% coinsurance of the drug, or a copayment ($3.70 for a generic drug or a drug that is treated like a generic, $9.20 for all other drugs). Important Info: Cost-sharing may change depending on the level of help you receive, the pharmacy you choose (such as Standard Retail, Mail Order, Long-Term Care, or Home Infusion) and when you enter any of the four stages of the Part D benefit. For more information about the costs for Long-Term Supply, Home Infusion, or additional pharmacy-specific cost-sharing and the stages of the benefit, please call us or access our EOC online. Additional Covered Benefits Benefits Ascension Complete St. Vincent's Secure (HMO) H4343: 003 Premiums / Copays / Coinsurance Additional Telehealth The cost share of Medicare-covered additional telehealth Services services with primary care physicians, specialists, individual/group sessions with mental health and psychiatric providers and other health care practitioners within these practices will be equal to the cost share of these individual services’ office visits. Opioid Treatment • Individual setting: $25 copay per visit Program Services • Group setting: $25 copay per visit Over-the-Counter $0 copay ($50 allowance per quarter) for items available via (OTC) Items mail There is a limit of 9 per item, per order, with the exception of certain products, which have additional limits. You are allowed to order once per quarter and any unused money does not carry over to the next quarter. Please visit the plan’s website to see the list of covered over the-counter items. Meals $0 copay Plan covers home-delivered meals (up to 3 meals per day for 14 days) following discharge from an inpatient facility or skilled nursing facility. Services are contingent on medical necessity and Case Management review and prior authorization to the vendor. Chiropractic Care Chiropractic services (Medicare-covered): $20 copay per visit Additional Covered Benefits Benefits Ascension Complete St.

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